Sigmoidoscopy for Emergent Decompression
Sigmoidoscopy is the most appropriate emergent management for this elderly patient with sigmoid volvulus, as she presents without signs of peritonitis, perforation, or septic shock. 1, 2
Initial Clinical Assessment
The key decision point is determining whether the patient requires immediate surgery versus endoscopic decompression. Based on the presentation described—abdominal distension and mild diffuse tenderness without signs of peritonitis or septic shock—this patient is a candidate for urgent endoscopic decompression rather than emergent laparotomy. 1, 2
When to Proceed Directly to Surgery
Emergent laparotomy is indicated only when patients present with: 1, 2
- Septic shock
- Clinical signs of bowel ischemia or perforation
- Peritonitis on examination
This patient does not meet these criteria based on the clinical description provided.
Endoscopic Decompression as First-Line Treatment
For uncomplicated sigmoid volvulus, endoscopic decompression (sigmoidoscopy) is the first-line treatment with a success rate of 70-91% and low complication rates of 2-4.7% in geriatric patients. 1, 2
Why Sigmoidoscopy Over Other Options
- Barium enema is not appropriate for acute management and has been largely abandoned in favor of direct endoscopic visualization and decompression 3
- Nasogastric decompression does not address the closed-loop obstruction at the sigmoid level and is ineffective for sigmoid volvulus 1
- Emergent laparotomy carries significantly higher mortality (12-20%) compared to elective surgery after successful decompression (5.9%) 2, 4
Critical Management Algorithm
Step 1: Urgent Sigmoidoscopy
Perform flexible sigmoidoscopy to decompress the volvulus and assess for mucosal ischemia. 1, 2
Step 2: Assess Viability During Endoscopy
- If viable mucosa is seen: successful decompression converts emergency to elective situation 1, 3
- If purplish-black ischemic mucosa is observed: proceed immediately to surgery 5
Step 3: Post-Decompression Management
After successful endoscopic decompression, sigmoid colectomy should be performed during the same hospital admission to prevent recurrence, which occurs in 45-71% of cases without definitive surgery. 1, 2
Special Considerations for This Elderly Patient with Dementia
High-Risk Patient Factors
This patient's advanced age and dementia from a skilled nursing facility place her at higher surgical risk. However, the 2023 World Society of Emergency Surgery guidelines emphasize that age over 60 years and institutionalization are risk factors for mortality with emergency surgery, making successful initial endoscopic decompression even more critical. 1
Definitive Treatment Timing
Despite her comorbidities, elective sigmoid resection during the index admission is strongly recommended because: 1, 2
- Recurrence rates without surgery are 63% at 3 months, 47% at 6 months 1
- Mortality after conservative treatment alone is 9-36% 1
- Each recurrent episode increases risk of ischemia, perforation, and need for emergency surgery 5
Alternative for Extremely High-Risk Patients
If this patient is deemed too high-risk for elective surgery after successful decompression, percutaneous endoscopic colopexy (PEC) can be considered as a bridge procedure in patients with median age 90 years and ASA score of 4, though this still carries a recurrence risk. 6
Common Pitfalls to Avoid
Do not delay endoscopic decompression while obtaining advanced imaging if the diagnosis is clear on plain radiography and the patient is hemodynamically stable. 1, 2
Do not discharge the patient after successful decompression without planning definitive surgery during the same admission—this is associated with recurrence rates exceeding 60%. 1, 7
Do not perform detorsion alone or non-resectional procedures (sigmoidopexy, mesosigmoidopexy) as these are inferior to sigmoid colectomy for preventing recurrence. 1